MEDICARE: ORTHOPEDIC AND SPORTS PHYSICAL THERAPY CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	5501004651	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	64-30126	OTHER	MI	IBA/PHP PROVIDER NUBMER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	305174	OTHER	MI	CHP #, HEALTH PLAN MNGT

General Provider Information

NPI Number	:	1811908650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPEDIC AND SPORTS PHYSICAL THERAPY CENTER, INC

Provider Business Mailing Address
First Line	:	PO BOX 8704
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49023-8704
Country	:	US
Telephone Number	:	269-925-9491
Fax Number	:	269-925-9553

Provider Business Practice Location Address
First Line	:	1850 PIPESTONE RD
Second Line	:	SUITE 202
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-2304
Country	:	US
Telephone Number	:	269-925-9491
Fax Number	:	269-925-9553

Authorized Official
Title or Position	:	PRESIDENT/PHYSICAL THERAPIST
Name	:	MR. RICARTHUR DANO LONTOC
Credential	:	P.T.
Telephone Number	:	269-925-9491

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	08/22/2020

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Directions to “ORTHOPEDIC AND SPORTS PHYSICAL THERAPY CENTER, INC ” Practice Location

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